Indications for Exercise Stress Testing

CARDIOLOGY

What Are the Indications for Exercise Stress Testing?

The following is a summary of guidelines for stress testing that have been proposed by several professional organizations.

  • Diagnose CAD in symptomatic patients with symptoms suggestive of angina who are at intermediate risk of acute coronary syndrome. Patients w/ high may go straight to cath. Don’t stress patients with ongoing UA.
  • Risk stratification in patients who have had an episode of ACS. Patients with acute chest pain or dyspnea on exertion. I.e. patients with chest pain r/o ACS.  Wait for a relief of symptoms and following the evaluation for ACS or infarction before stressing.
  • Patients with a recent ACS may get stress 3 months later if it wasn’t done prior to d/c from the hospital.
  • Patients with known CHD and new or worsening symptoms–i.e. if there has been a clinical change (ie, new or worsening symptoms) in a patient with known CAD.
  • Patients with prior coronary revascularization – for patients ≥5 years after CABG or ≥2 years after PCI, stress testing may be appropriate on a one-time basis for the asymptomatic patient.
  • Patients with valvular heart disease – Stress echocardiography may be done to evaluate valvular heart disease, such as severe mitral stenosis without symptoms, moderate mitral stenosis with symptoms, severe mitral or aortic regurgitation.
  • Patients with newly diagnosed heart failure or cardiomyopathy – Stress testing is indicated and appropriate to evaluate for ischemic heart disease as the cause for heart failure or a cardiomyopathy of uncertain etiology, assuming that coronary angiography has not already been planned or performed. Even if angiography has already been performed, stress testing may still be indicated to determine whether the myocardium is viable and to plan the revascularization.
  • Patients with select arrhythmias
  • Patients with chronic left ventricular dysfunction and CHD who are candidates for revascularization.
  • Patients undergoing elective non-cardiac surgery – For preoperative evaluation of patients prior to elective noncardiac surgery, patients with active cardiac conditions should undergo evaluation (including stress test) and treatment prior to the planned surgery.
  • Prediction of cardiovascular events,
  • determining myocardial viability before revascularization
  • assessing prognosis after MI or in patients with chronic angina,
  • evaluating cardiac risk before noncardiac surgery.
  • Determine exercise tolerance.
  • Localize ischemia (requires imaging).
  • Assessment of chronotropic competence,
  • Evaluation of exercise-induced symptoms,
  • Evaluation of unexplained syncope in patients at intermediate to high risk of CAD, and
  • Assessment of response after medical or surgical interventions in patients with valve disease, arrhythmias, or other heart diseases.

Cardiac stress testing for screening of asymptomatic low-risk patients is generally not indicated or appropriate.

Summary from the AHA

Purposes of Exercise Testing

Exercise testing has been used for the provocation and identification of myocardial ischemia for >6 decades, and during this time additional purposes for testing have evolved. Exercise testing now is used widely for the following:

  • Detection of coronary artery disease (CAD) in patients with chest pain (chest discomfort) syndromes or potential symptom equivalents

  • Evaluation of the anatomic and functional severity of CAD

  • Prediction of cardiovascular events and all-cause death

  • Evaluation of physical capacity and effort tolerance

  • Evaluation of exercise-related symptoms

  • Assessment of chronotropic competence, arrhythmias, and response to implanted device therapy

  • Assessment of the response to medical interventions

During the past several decades, exercise testing has been focused increasingly on assessment of cardiovascular risk, not simply detection of coronary obstruction. Ultimately, improved clinical outcome is a major goal of exercise testing.

 

Reference

Circulation. 2013 Aug 20;128(8):873-934. https://www.ncbi.nlm.nih.gov/pubmed/23877260

http://circ.ahajournals.org/content/128/8/873.long

Am Fam Physician. 2017 Sep 1;96(5):293-299A.

Askew, J. Wells, et al. Selecting the optimal cardiac stress test. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2017.

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